Healthcare Provider Details

I. General information

NPI: 1871752030
Provider Name (Legal Business Name): MICHAEL JOHN KACHURA LPC; LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2008
Last Update Date: 01/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3925 OLD LEE HWY SUITE 52A
FAIRFAX VA
22030-2426
US

IV. Provider business mailing address

3925 OLD LEE HWY SUITE 52A
FAIRFAX VA
22030-2426
US

V. Phone/Fax

Practice location:
  • Phone: 703-385-7575
  • Fax: 703-385-7578
Mailing address:
  • Phone: 703-385-7575
  • Fax: 703-385-7578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701001253
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0717000346
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: